The leadership team at Cambridge Health Alliance expected a rise in emergency department volume after healthcare reform and universal access to coverage became law in Massachusetts in 2006. Indeed, between 2006 and 2008, overall ED volume at the safety-net health system's three EDs rose 4% for a variety of reasons, not all related to improved access.

Assaad Sayah, MD, senior vice president of primary and emergency care and chief of emergency medicine, says poor patient satisfaction and the overall change in the healthcare environment pushed the team to redesign ED patient flow. After abandoning a traditional triage and registration model, the first step was to install "patient partners," or nonclinicians who greet patients as they come in and do a mini-registration to get the patient's name and chief complaint, Sayah says. Patients are then taken to "rapid assessment," a specific section of the ED where a physician assistant and nurse do a fast assessment of the patient. If the treatment is nonacute, the patient can be treated in the unit and discharged by the PA.

The rapid assessment unit solved several problems, Sayah says. It eliminated the need for space being used by express care, registration, and triage. The unit also combined nursing resources that had been used for express care and triage, which allowed for improved ability to care for multiple patients at the same time. Within a year of rapid assessment being implemented at CHA's Whidden campus, for example, median total length of ED stay dropped from 220 minutes to less than 140. And patients who left without being seen dropped from over 4% of total volume in 2006 to consistently below 0.5%.